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Nursing 101 Fundamentals of Nursing Practice Exam 1, Part 2 – Q’s and A’s
Nursing 101 Fundamentals of Nursing Practice Exam 1, Part 2 – Q’s and A’s
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Nursing 101 Fundamentals of NursingPractice Exam 1, Part 2 – Q’s and A’s
During the change-of-shift report the night nurse states that a client
mentioned having a bad experience with surgery in the past. The nurse was
called away and was unable to continue the conversation with the client. The
nurse tells the day shift nurse about the comment and notes that the client
appears anxious. When the day shift nurse visits the client to clarify the
client's bad experience with surgery, the nurse is exhibiting which aspect of
critical thinking?
A. Integrity
B. Discipline
C. Confidence
D. Perseverance - -D. Discipline
Discipline includes completing the task at hand, including assessments
(which were not completed on the previous shift). Integrity includes
recognizing when one's opinions conflict with those of others and finding a
mutually satisfying solution. Confidence is demonstrated in one's
presentation and belief in one's knowledge and abilities. Perseverance helps
the critical thinker to find effective solutions to client care problems,
especially when they have been previously unresolved.
-A client tells the nurse, "I'm not happy with the way the patient care
technician did my bath. He just seemed to be in a hurry and did not wash my
back like I asked." The nurse decides to go talk with the technician to learn
his side of the story as well. This is an example of:
A. Fairness
B. Curiosity
C. Risk taking
D. Responsibility - -A. Fairness
Fairness involves analyzing all viewpoints to understand the situation
completely before making a decision. Curiosity gives the critical thinker the
motivation to continue to ask questions and learn more. Risk taking involves
trying different ways to solve problems.
-The surgical unit has initiated the use of a pain rating scale to assess the
severity of clients' pain during their postoperative recovery. The nurse
assigned to a client can look at the pain flow sheet to see the client's pain
scores over the last 24 hours. Use of the pain scale is an example of
adherence to which intellectual standard? - -D. Consistency
,Using the same pain scale for all clients and ratings promotes consistency—
each nurse has the same measurement scale to compare assessments.
Relevance refers to how applicable the assessment is. An assessment has
depth when it deals with less obvious issues. Specificity refers to the ability
of the assessment to provide information about the particular problem of
interest.
-During the day the nurse spends time instructing a client in how to self-
administer insulin. After discussing the technique and demonstrating an
injection, the nurse asks the client to try it. After the client makes two
attempts it is clear that the client does not understand how to prepare the
correct dose. The nurse discusses the situation with the charge nurse and
asks for suggestions. This is an example of:
A. Reflection
B. Risk taking
C. Problem solving
D. Client assessment - -C. Problem Solving
This is an example of problem solving because the nurse is taking a problem
to a supervisor for help in finding a different approach. Reflection is the
process of purposefully thinking back and recalling a situation to discover its
purpose or meaning. Risk taking involves trying a different approach. Client
assessment is the first step in the process of instruction.
-A nurse uses an institution's procedure manual to confirm how to insert a
Foley catheter. The level of critical thinking the nurse is using is:
A. Commitment
B. Scientific method
C. Basic critical thinking
D. Complex critical thinking - -C. Basic critical thinking
At the basic level of critical thinking, a learner trusts the experts and follows
a procedure step by step. Complex critical thinkers separate themselves
from authorities and analyze and examine choices more independently.
Commitment is the third level of critical thinking in which the person
anticipates the need to make choices without assistance from others. The
scientific method is a process of problem solving.
-A nurse refers to a client's postsurgical written plan of care, noting that the
client has a drainage device collecting wound drainage. The surgeon is to be
notified when drainage in the device exceeds 100 ml for the day. The nurse
carefully notes the amount of drainage currently in the device. This is an
example of:
A. Planning
B. Evaluation
C. Assessment
,D. Intervention - -C. Assessment
Assessment is the process of observing and collecting data. Planning is the
step in which the diagnosis is analyzed for problem resolution. Intervention
consists of the steps actually taken after planning. Evaluation measures the
effectiveness of the plan.
-The nurse asks a client how she feels about impending surgery for breast
cancer. Before initiating the discussion the nurse reviewed information about
loss and grief in addition to therapeutic communication principles. The
critical thinking component involved in the nurse's review of the literature is:
A) Experience
B) Problem solving
C) Knowledge application
D) Clinical decision making - -C. Knowledge application
The nurse sought appropriate information to be able to communicate more
knowledgeably with the client. Experience is acquired through clinical
learning situations. Problem solving is a series of steps to resolve a problem.
Clinical decision making is a process in which critical thinking steps are
followed for problem resolution.
-Which of the following is the most accurate information to give a nurse
during change-of-shift reporting?
A) Client refuses to take medications.
B) Client reports sharp pain in left anterior knee.
C) Client encouraged to consume more fluids.
D) Client expressed concern about pending surgery. - -B. Client reports
sharp pain in elft anterior knee
The information in option 2 represents objective data that the nurse can use
as part of baseline information. "Encouraged" and "more" are vague terms.
"Concern" is also vague; relating the exact concern would be more accurate.
Option 1 may be true, but accurate data would also report why the client
refused medication.
-On entering a client's room during change-of-shift rounds, the nurse notices
that the client and spouse have their backs turned to each other, and both
have their arms folded across their chests. The best action for the nurse to
take at this time is to:
A) Introduce himself or herself and begin discharge teaching.
B) Proceed with the tasks the nurse was intending to perform.
C) Say nothing and leave quickly, closing the door behind.
D) Ask the client and spouse if they need some time alone right now. - -D.
Ask the client and spouse if they need smoe time alone right now.
, The situation suggests that the nurse entered during a stressful time.
Offering privacy would be appropriate. Because the situation indicates
tension between the couple, this is not the time to initiate teaching.
-The nurse is assessing the urinary history of a middle-aged married woman.
The nurse asks her if she gets up at night. She replies, "Yes." What other
question should the nurse ask?
A) "How many times do you get up at night?"
B) "How long have you been getting up at night?"
C) "Why do you get up at night?"
D) "How easily do you go back to sleep after you get up?" - -C. "Why do you
get up at night?"
Perhaps it is the client's husband who is getting up in the middle of the night
because of a prostate problem, and this is why she is awakened. The nurse
should not assume nocturia without further assessment questions.
-A client with diabetes mellitus who takes daily insulin injections is
scheduled for surgery the next day. The client is to take nothing by mouth
(NPO status) after midnight. The nurse questions whether insulin should be
given the morning of surgery. This is an example of:
A) Problem solving
B) Previous experience
C) Clinical practice guideline
D) Scientifically based clinical judgment - -D. Scientifially based clinical
judgment
The nurse is demonstrating awareness of the effect of insulin, which is to
lower blood glucose level. Because the client will be NPO status for a long
period of time, no calories will be consumed. Giving the usual injection of
insulin could cause the client to experience hypoglycemia.
-The client is a 65-year-old overweight woman with multiple medical
diagnoses, including diabetes mellitus type 2, hypertension, and residual
right-sided weakness resulting from a previous cerebrovascular accident.
What tool should be used to plan her care?
A) Care plan
B) Care map
C) Concept map
D) Critical thinking - -C. Concept map
A concept map is a visual representation of client problems and interventions
that shows their relationships to each other and allows easy synthesis of
data about the client.
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